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0SN "N &90:l[ E[H 8 upr auiil paniaOa� �• . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 •;�:=� (209)468-3420 Fax, (209)464-0138 Web:www.sjgov.org/ehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following conditions must be met The generator or health care professional generates less than 20 pounds of medical waste per week,transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with$77.00 fee to: San Joaquin County Environmental Health Department APPROV Medical Waste Management Program Ii. 1868 East Hazelton Avenue, Stockton,CA 95205-6232Ki Medical Waste Hauler Information New Renewal Medical Office/Business Name: 'h e.( e-� - ; Medical Office/Business Address A AJ M Ci State Zip Code Contact Person: Phone Number. Storage Facility Name: ;Storage Facility Facility Address: City State zip Code Permitted Treatment Facility Name: , C Permitted Treatment Facility Address: ity State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: k V1 Title: 'biYc.c� aCz-re. kZQ"/_PF 2. Name: n6rA A Title: 'Ky) 3. Name: 1G., p �;r _�e� Title: L; �n Y•vz�- A copy of this exemption and a tracking document shall be In employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Sig a re: Date: o� 13 Title: DO NOT WRITE BELOW THIS LINE RENS Application Approval:ai r.._`� VV`, Date: _a_6_rba Expiration Date:�-K/ /F'-Date Paid: i 1—.2- /13 Cash or hl;c : aLl� Received By: F_HD 45-016/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION